How Portuguese doctors perceive Traditional Chinese
Medicine and its implementation in the
National Health System: A Pilot Study
Carina Vieira Teixeira
Master Thesis on Traditional Chinese Medicine
Carina Vieira Teixeira
How Portuguese doctors perceive Traditional Chinese Medicine and
its implementation in the National Health System: A Pilot Study
Master thesis proposal in Traditional
Chinese Medicine (TCM) submitted to
Abel Salazar Institute for Biomedical
Sciences at Porto University.
Supervision
– Prof. Doctor Henry J.
Greten
Category – Associate Professor
Affiliation
– Instituto de Ciências
Biomédicas de Abel Salazar da
Universidade do Porto;
Co-supervision – Dr. Nuno Correia
Category – Invited Adjunct Professor
Affiliation – Nursing School of Porto
Abstract
Introduction: Even without official numbers, it is possible to state that Traditional Chinese
Medicine (TCM) has had tremendous growth in recent years in Portugal. The best-known TCM therapy is acupuncture and because of that, the two concepts are usually confused. The Ordem dos Médicos (OM) only recognizes acupuncture as a medical competence, and so recognition of TCM and definition of who should be allowed to practise TCM therapies has been a subject of deep controversy.
Objectives: This pilot study has two overall objectives: (1) to collect preliminary data to
understand how Portuguese MD perceive TCM and what MD think about TCM implementation in the NHS; and (2) to assess if the research instrument chosen (a questionnaire) is the best method to assess Portuguese MD perception of TCM and their opinion about TCM implementation in the NHS.
Method: A questionnaire was designed and made available online. The questionnaire’s
goals and link was sent to several entities and to some MD directly (part of a paid contacts database) by e-mail. The contacted entities passed the received information to their MD contacts.
Results: This study allowed access to preliminary data showing that Portuguese MD are
open-minded towards TCM and that they want it to be included in the NHS.
Conclusion: This pilot study revealed several problems with the questionnaire’s
construction and with the research method chosen. Before extending this initial survey to a field study, the questionnaire and investigation method should be reconsidered to ensure the study’s internal and external validity.
Resumo
Introdução: Mesmo sem números oficiais, é possível afirmar que em Portugal, nos
últimos anos, a Medicina Tradicional Chinesa (MTC) tem tido um enorme crescimento. A terapia de MTC mais conhecida em Portugal é a acupunctura e, talvez por isso, seja comum confundir os dois conceitos. A Ordem dos Médicos (OM) só reconhece acupunctura como competência médica, e por isso o reconhecimento da MTC e a definição de quem deve ser autorizado a exercer as terapias da MTC tem estada envolta em grande controvérsia.
Objetivos: Este estudo piloto tem dois grandes objetivos: (1) compreender de que forma
os Médicos Portugueses percecionam a MTC e perceber a opinião destes relativamente à implementação da MTC no SNS; (2) perceber se o instrumento de investigação escolhido (um questionário) é o melhor método para aferir a perceção dos médicos portugueses sobre a MTC e sobre a opinião destes relativamente à implementação da MTC no Sistema Nacional de Saúde (SNS).
Método: Foi desenhado um questionário e tornado disponível online. Os objetivos do
questionário, e o link para aceder a este, foram enviados a diversas entidades e a alguns médicos diretamente (faziam parte de uma base de contactos paga) por e-mail. As entidades contactadas reenviaram a informação usando listas de distribuição internas.
Resultados: Este estudo permitiu acesso a dados preliminares que mostram que os
Médicos Portugueses são recetivos em relação à MTC e que consideram que esta devia ser incluída no SNS.
Conclusão: Este estudo piloto revelou vários problemas com a construção do
questionário e com o método de investigação escolhido. Antes de se avançar para um estudo de campo alargado, o questionário e o método de investigação devem ser reconsiderados de forma a garantir a validade interna e externa do estudo.
Palavras-chave: Medicina Tradicional Chinesa; Portugal; médicos portugueses; opinião;
Acknowledgments
I would personally like to thank all those who contributed to this work in any way: To Professor Jorge Machado for helping me when I was prepared to give up. To my patients, who made me seek something new to answer their problems.
To all the friends that I made during these years, who contributed to the person that I am today. To Filipa and Ana Teresa for our tea time. To Ana Patricia, Sara and Sandra for all the complicity. To Liliana and Yesenia for all the craziness and to Claudia for all the serenity.
To my parents, Fátima and Jorge, who gave me everything, and with their sacrifice helped me to reach so far. They truly made me the woman that I am today.
To my niece Leonor, the new light in my life.
To Pedro, my love and my best friend, for all these years of patience, comprehension and support.
To my brother, Claudio, the rock of my life, without whose unconditional support and guidance this work could not have been done. Thank you for 26 years of friendship.
“Everyone has the right to benefit from any measures enabling him to enjoy the highest possible standard of health attainable.”
Index
1. Introduction ... 1
2. Methodology ... 5
2.1. Research Instrument and Strategy for Collecting Data ... 5
2.2. Ethical Considerations ... 6
3. Results ... 7
4. Discussion ...11
5. References ...13
Annex A: Critérios de Reconhecimento de Cursos de Pós‐Graduação em Acupunctura Médica e Obtenção da Competência em Acupunctura Médica ...15
Annex B: Questionnaire ...20
TABLE INDEX
TABLE 1 – ENTITIES CONTACTED ENTITIES VIA E-MAIL FOR QUESTIONNAIRE DISSEMINATION ... 5 TABLE 2 – ANSWERS TO THE FIRST 9 QUESTIONS RELATED TO SAMPLE CHARACTERIZATION ... 7 TABLE 3 – ANSWERS TO QUESTIONS 10 TO 17 AND TO QUESTION 20 FROM THE QUESTIONNAIRE ... 8 TABLE 4 – THE PERCEPTION OF RISK OF DIFFERENT THERAPIES AND OF ACUPUNCTURE, ACCORDING TO THE PERFORMER ... 10
FIGURE INDEX
1. Introduction
Traditional Chinese Medicine (TCM) “is a system of sensations and findings designed to establish a functional vegetative state which can be treated with acupuncture, qigong, tuina, Chinese pharmacology and dietetics” [Greten, 2010]. TCM is already recognized as being effective in treating some diseases by the World Health Organization [WHO, 2002] and as being cost effective by the National Institute for Health and Clinical Excellence in the UK [NICE, 2009].
The TCM diagnosis comprises four steps:
1. The constitution, which reflects the patient’s inner nature and has expression in his physical appearance;
2. The agent, that is, the pathogenic factor affecting the patient;
3. The Orb, which is the group of symptoms that can be correlated to an organ; and 4. The guiding criteria, which in fact is sub-divided in four guiding criteria as
illustrated in Figure 1.
Figure 1 – The Four Components of Functional diagnosis [Greten, 2010]
With the diagnosis established, the TCM practitioner chooses one or more therapies to treat the patient. He can choose from: acupuncture, which is the act of needling points in the skin; Chinese pharmacology; dietetic advice; tuina, which is Chinese massage, and
How Portuguese doctors perceive Traditional Chinese Medicine and its implementation in the National Health System: A pilot study 2 qigong, which is composed of exercises designed to work out and balance the Qi, which is the energy in the body.
Of all TCM therapies, acupuncture is the best known, and because of this it is commonly referred to as a TCM synonym. This confusion is usual, but it is important to understand that acupuncture, being part of TCM, cannot be mistaken as being TCM in itself.
In Portugal, TCM is not recognized but nevertheless, and even without official numbers, it is possible to say that TCM has had tremendous growth in recent years. Lacking more solid proof, the blossoming of private clinics all over the country providing this type of service at least proves there is a market out there for them, meaning that patients are receptive to such therapies. In addition, for the past two years, national insurance companies have included some TCM therapies (acupuncture, phytotherapy) in their insurance plans.
Even in education, it is possible to realize the growth of TCM in Portugal. The supply of TCM training is extensive, from weekend courses to five-year courses. Some of these are open to anyone interested, and others are addressed to healthcare providers. Portuguese Medical Doctors (MD) can even attend post-graduate courses in “medical acupuncture” lectured in almost all medical schools (Faculdade de Medicina da Universidade Nova de Lisboa; Instituto de Ciências Biomédicas Abel Salazar da Universidade do Porto, Faculdade de Medicina da Universidade de Coimbra; Escola de Ciências da saúde da Universidade do Minho).
Portuguese MD is one of the few professional classes with self-established rules regarding education in Acupuncture for doctors. Despite this self-regulation, the Ordem dos Médicos (OM) has no official position on TCM as a whole medical system, only recognizing acupuncture according to the school of “medical” or “contemporary” acupuncture. This view understands acupuncture as a technique of neural modulation and neurophysiologic pathway support for all treatment strategies.
The OM has recognized acupuncture as a medical competence since 2002 and has established rigorous admission criteria to this competence as proposed by the Portuguese Acupuncture Medical Society (see Annex A).. In Portugal, acupuncture is already offered in some public and private hospitals and primary healthcare centres, mainly integrated in Chronic Pain Units [Ferreira, 2010].
Recognition of TCM and definition of who should be allowed to practise TCM therapies has been a subject of deep controversy in Portugal for some years now [Almeida, 2008].
How Portuguese doctors perceive Traditional Chinese Medicine and its implementation in the National Health System: A pilot study 3 On one hand, the OM opposes the idea of acupuncture being exerted by non-medical personnel, and on the other, the acupuncture lobby pushes government to allow acupuncture by medical laypersons. With a vast availability of treatment and education in TCM, and due to patients’ easy access to these treatments, national regulation on TCM is required.
Recently, the Portuguese Government approved the text of bill 111/XII/2 on unconventional therapies [Presidência do Conselho de Ministros, 2012]. This document states that the practitioners of unconventional therapies must hold a university degree that will give them access to a professional card with public registration. This bill recognizes the following professions (by enforcing Law nr. 45/2003): acupuncturist, herbalist, homeopath, naturopath, osteopath and chiropractor. Once more, TCM is not recognized, but when looking at this bill’s definition of acupuncture, we realize that again the definition of TCM and acupuncture were mixed up. This bill defines acupuncture as a therapeutic system directed to diagnosing, preventing and treating sickness, stating that acupuncture means needling with a needle as a way to stimulate points, but also mentions that other methods (to stimulate points) can be used, such as dietetics, massage, energetic exercises, prepared herbs and lifestyle counselling, which is clearly outside the scope of acupuncture.
Considering the described context, it seems interesting to try to understand the real perception of TCM held by Portuguese MD, as well as their opinion on TCM implementation in the National Health System (NHS). To the best of my knowledge, there are no specific studies that try to understand the doctor’s point of view on TCM, in Portugal. Outside Portugal, to the best of my knowledge, there are no specific studies addressing this subject. Outside Portugal, there are however studies with similar objectives to the one proposed, but more directed to opinions, attitudes and interests in alternative and complementary medicines [Rhode et al., 2008, Kurtz et al., 2003, White et al., 1997, Stange et al., 2008, Tiwana and Prestwich, 2011], or just to investigate acupuncture [Lipman et al., 2003, Price and White, 2004, Shao et al., 2005].
Similar to other surveys [Rhode et al., 2008, Kurtz et al., 2003, White et al., 1997, Tiwana and Prestwich, 2011, Lipman et al., 2003, Price and White, 2004, Shao et al., 2005], this pilot study will be based on a questionnaire designed to collect MD opinions about their perception of TCM.
How Portuguese doctors perceive Traditional Chinese Medicine and its implementation in the National Health System: A pilot study 4
1. To collect preliminary data to understand how Portuguese MD perceive TCM and what MD think about TCM implementation in the NHS; and
2. To assess if the research instrument chosen (a questionnaire) is the best method to assess Portuguese MD perception of TCM and their opinion about TCM implementation in the NHS.
More specifically, this study’s objectives are:
To collect preliminary data;
To find out if Portuguese MD know what TCM is;
To assess Portuguese MD opinion of TCM;
To quantify if Portuguese MD would recommend TCM to their patients;
To determine who doctors think should be allowed to practise TCM;
To find out how Portuguese MD perceive the risk associated with TCM therapies;
To find out how Portuguese MD perceive the risk associated with acupuncture, according to the performer;
To determine if Portuguese MD support the inclusion of TCM in the NHS.
To develop a questionnaire fit for the main objectives;
To test the questionnaire’s suitability;
To assess the success of recruiting participants to the study;
To determine what resources are needed for a planned study;
This Master thesis is organized as follows: this section contextualizes the thesis and its goals; section 2 explains the methodology used; section 3 presents the pilot study results; and section 4 presents the discussion, outlining the weaknesses found in the presented approach, and proposing changes to circumvent them in a new study.
How Portuguese doctors perceive Traditional Chinese Medicine and its implementation in the National Health System: A pilot study 5
2. Methodology
2.1. Research Instrument and Strategy for Collecting Data
As mentioned, a questionnaire was the method chosen to accomplish the previously mentioned objectives. Since there were no previous studies/questionnaires (in Portugal or elsewhere) directed exclusively to MD opinion on TCM, the questionnaire was designed from scratch.
With the intent of reaching as many MD as possible, an e-mail was prepared with a brief introduction to the on-going study, the questionnaire’s link, a request for participation, and a second request for further dissemination. This e-mail was sent to several entities (see Table 1) and to a paid database that contained 3318 e-mail addresses of doctors, dentists, hospitals, associations, pharmacies, etc. The lack of response from most entities does not necessarily mean they did not forward the request. It simply means they did not inform about the completion of the request.
Table 1 – Entities contacted entities via e-mail for questionnaire dissemination
Entities Replies
Ordem dos Médicos Answered saying that the OM’s policy is not to pass this type of request to their associates.
Sindicato Independente dos Médicos Did not reply Federação Nacional dos Médicos Did not reply Centro de Medicina Física e de Reabilitação
Rovisco Pais
Did not reply
ARS Norte Did not reply
ARS Centro Did not reply
ARS Lisboa e Vale do Tejo Did not reply
ARS Alentejo Did not reply
Serviço de Saúde da Região Autónoma da Madeira
Did not reply
Direção Regional da Saúde dos Açores Answered positively, with a copy of the e-mail that was sent to Azorean MD, where the MD were encouraged to reply to this request.
Grupo HPP Saúde Did not reply
Grupo Assistência Medica Integral Did not reply Hospital de Dia do Porto Did not reply Hospital Privado de Alfena Did not reply Hospital Privado da Trofa Did not reply Hospital de Dia de Famalicão Did not reply Hospital Privado da Boa Nova Did not reply Hospital Privado de Braga Did not reply Hospital de Dia da Maia Did not reply
How Portuguese doctors perceive Traditional Chinese Medicine and its implementation in the National Health System: A pilot study 6 Hospital Particular do Algarve Did not reply
Casa de Saúde São Mateus Did not reply Clínica Quadrantes Miraflores Did not reply Casa de Saúde Carnaxide Did not reply Casa de Saúde de Amares Did not reply Hospital da Cruz Vermelha Did not reply Hospital Particular de Viana do Castelo Did not reply Sociedade Portuguesa de Reumatologia Did not reply Sociedade Portuguesa de Pediatria Did not reply Sociedade Portuguesa de Neuropediatria Did not reply Sociedade Portuguesa de Gastrenterologia Did not reply Sociedade Portuguesa de Cardiologia Did not reply Sociedade Portuguesa Médica de Acupunctura Did not reply
The questionnaire (see Annex B) was intentionally kept short to encourage participants to complete it. The questionnaire was designed with a total of 20 questions plus 3 sub-questions, the first 9 questions being of a biographical nature. Although the questionnaire was related to TCM, acupuncture was singled out, to try to understand if MD think the risk of this practice depends on the professional background of the practitioner. This was done due to the usual confusion between TCM and acupuncture and because it is expected that most doctors do not know TCM thoroughly.
The questionnaire was available online through the Google Docs Offline application, for one and a half months, from 30th of July, 2012 to September the 14th, 2012. The questionnaire was directed to all Portuguese MD. In the context of this questionnaire, all MD working in Portugal, and therefore registered in the OM, were considered as Portuguese MD, regardless of their nationality.
2.2. Ethical Considerations
This study, as well as the questionnaire, was submitted to an ethical committee at the Instituto de Ciências Biomédicas de Abel Salazar da Universidade do Porto and approved on the 27th of July 2012 (see Annex C). In the e-mail requesting doctors’ participation, it was also made clear that the questionnaire was anonymous and the collected data was for the exclusive use of this study.
How Portuguese doctors perceive Traditional Chinese Medicine and its implementation in the National Health System: A pilot study 7
3. Results
The first 9 questions of the questionnaire intended to characterize the sample; the complete results can be seen in Table 2. A total of 87 MD comprised the sample, 46 males and 41 females, and 50.6% of the MD were between 30 and 49 years old. Of the 87 MD, 96.6% took their medical degree in Portugal and 31.0% are specialized in Family Medicine. The majority of MD (80.5%) work for the NHS, exclusively or not. The North Coast of Portugal is most represented in this questionnaire, with 31.0% of the MD who participated in this study. Most of the MD (83.9%) had no prior education in TCM.
Table 2 – Answers to the first 9 questions related to sample characterization
Question F F (%) 1. Age < de 30 Years 9 10.3 30 to 49 Years 44 50.6 50 to 59 Years 23 26.4 60 to 69 Years 11 12.6 >70 Years 0 0.0 2. Gender Female 41 47.1 Male 46 52.9 3. Nationality Portuguese Other 85 2 97.7 2.3 4. Where did you take your
medical degree? Portugal Other 84 3 96.6 3.4 5.
If in the last question you answered "Portugal”, select the university where you took your medical degree
Universidade do Minho 1 1.1
Faculdade de Medicina da Universidade do Porto 32 36.8 Instituto de Ciências Biomédicas Abel Salazar, Porto 10 11.5 Faculdade de Medicina da Universidade de Coimbra 18 20.7 Universidade da Beira Interior 0 0.0 Universidade de Lisboa – Faculdade de Medicina 14 16.1 Faculdade de Ciências Médicas da Universidade Nova de Lisboa 9 10.3
Universidade do Algarve 0 0.0
6. Medical Speciality
Anaesthesiologist 4 4.6
Angiology
and Vascular Surgery 2 2.3
Surgery 2 2.3
Plastic Surgery 1 1.1
Gastroenterologist 23 26.4
Dentist 2 2.3
Gynaecology and obstetric 2 2.3
Family Doctors 27 31.0 Internal Medicine 5 5.7 Orthopaedic 1 1.1 Otolaryngology 2 2.3 Paediatrics 6 6.9 Pulmonologist 1 1.1 Psychiatric 2 2.3 Radiotherapy 1 1.1
Oral Surgery and Rehabilitation 1 1.1
Public Heath 2 2.3
Physical Health and Rehabilitation 2 2.3 Competence in Acupuncture 1 1.1 7. Workplace
Public 36 41.4
Private 17 19.5
Both 34 39.1
8. In what part of the country do you work?
North Coast 27 31.0 Central Coast 21 24.1 South Coast 10 11.5 Inner North 18 20.7 Inner Central 4 4.6 Inner South 1 1.1 Madeira 2 2,3 Azores 4 4,6
9. Do you have any education in TCM?
Yes, I have education in TCM 14 16.1
No 63 72.4
How Portuguese doctors perceive Traditional Chinese Medicine and its implementation in the National Health System: A pilot study 8 All data from the 10th question to the 17th plus the data related to the 20th question can be consulted in more detail in Table 3. Questions 10, 11, 15, 16 and 17.1 are multiple choice questions from the checklist type, allowing participants to indicate more than one answer, and so the sum of all percentages can be higher than 100%.
Table 3 – Answers to questions 10 to 17 and to question 20 from the questionnaire
Regarding MD opinion of TCM, 79.3% see TCM as “interesting”, followed by 24.1% of MD who see TCM as effective. To have a better perception of how MD perceive TCM, their opinions were subdivided into four groups called: interesting, positive, negative and
Questions F (%)
10. Traditional Chinese Medicine is…
Effective 24.1 Ineffective 1.1 Safe 11.5 Unsafe 4.6 Placebo 9.2 Interesting 79.3 Valueless 1.1
11. Forms part of Traditional Chinese Medicine…
Qigong 42.5 Chiropractics 12.6 Dietetics 13.8 Phytotherapy 50.6 Tuina 19.5 Hypnotherapy 1.1 Acupuncture 96.6 Aromatherapy 12.6 Shiatsu 26.4 Reiki 21.8 Hydrotherapy 5.7 12. Have you ever been submitted to a Traditional Chinese
Medicine treatment?
Yes 26.4
No 73.6
12.1 If you answered "yes" to the last question. Were you satisfied with the results?
Yes 87.0
No 13.0
13. Would you recommend Traditional Chinese Medicine to a patient?
Yes 23.0
Yes, I have already recommended 44.8
No 32.2
14. Do you think that Traditional Chinese Medicine treatments should be subject to medical prescription?
Yes 74.7
No 25.3
15. Who do you think should be allowed to study and practise Traditional Chinese Medicine?
Doctors 85.1 Pharmacists 12.6 Nurses 43.7 Psychologists 11.5 Physiotherapists 43.7 Occupational therapists 10.3 Other health professionals 10.3 Life sciences professionals 6.9
Anyone 10.3
16. Who do you think should be allowed to study and research Traditional Chinese Medicine?
Doctors 79.3 Pharmacists 23.0 Nurses 43.7 Psychologists 16.1 Physiotherapists 39.1 Occupational therapists 11.5 OAnother health professionals 10.3 Life sciences professionals 12.6
Anyone 16.1
17. In your workplace, do patients have access to unconventional therapies?
Yes 28.7
No 71.3
17.1. If you answered "yes" to the last question, what type of unconventional therapies do patients have access to?
Acupuncture 100.0 Osteopathy 13.6
Reiky 4.5
Others 4.5
20. Do you think that Traditional Chinese Medicine should be available in the National Health System? Yes 72.4
How Portuguese doctors perceive Traditional Chinese Medicine and its implementation in the National Health System: A pilot study 9 ambiguous. The “Interesting” group includes the answers of those MD who merely think that TCM is interesting, without adding any positive or negative opinion. The “Positive opinion” group includes those who find TCM safe and effective, the “Negative opinion” group includes the opinions that TCM is unsafe, a placebo, ineffective and without value. The last group is “Ambiguous”, composed of those MD who gave at the same time answers from the positive and negative groups. The majority (59.8%) of MD see TCM as interesting and 25.3% of the surveyed MD have a positive opinion of TCM.
To almost all MD (96.6%), the concept of TCM implies the use of acupuncture. The next therapies correctly associated with TCM were phytotherapy with 50.6% of the surveyed MD selecting it as being part of TCM and gigong, selected by 42.5% of the surveyed MD. TCM as composed of qigong, acupuncture, tuina, phytotherapy and dietetics was identified by 3 of the 87 MD.
Most Portuguese MD (73.6%) had never experienced a TCM treatment. Of the 23 MD who had already experienced a TCM treatment, 87.0% were satisfied with the results. The majority of MD (67.8%) said they were open to recommending TCM to their patients; in fact, 44.8% of MD had already recommended TCM to their patients at least once. Of the MD who had recommended TCM to their patients or were willing to do so, 57.9% have neither a positive nor negative opinion about TCM and 3.5% have a negative opinion, but even so, are willing to recommend TCM to their patients. Still concerning recommendation, only 2 of the 23 MD who had tried TCM treatments were not willing to recommend TCM to their patients. With the exception of MD from plastic surgery, oral surgery and rehabilitation, radiotherapy and public health, at least one MD from each specialty had recommended or was willing to recommend TCM treatments to their patients.
A medical prescription requirement for TCM treatments is defended by 74.7% of MD. In terms of the best suited professional to practise TCM, doctors were the preferred professionals with 85.1% preference, followed by nurses (43.7%) and physiotherapists (43.7%). Regarding exclusive performance by MD, most of the surveyed MD (65.5%) are of the opinion that TCM should not be performed exclusively by MD.
Only a minority of the MDs’ workplaces (28.7%) already offer unconventional therapies to their patients, and in all these places, at least acupuncture is available. A large proportion of MD (72.4%) think that TCM should be available on the NHS.
Answers to questions 18and 19 are based on a rating scale and therefore the data were arranged in a different table (see Table 4). For 52.9% of MD, acupuncture is the therapy with lowest risk, and tuina is the therapy where MD know least (71.3%) about its risk.
How Portuguese doctors perceive Traditional Chinese Medicine and its implementation in the National Health System: A pilot study 10 Concerning the acupuncture risk, taking into account the performer, more MD (66.7%) think the risk is lower when an MD performs acupuncture. When comparing the results of acupuncture’s general risk perception with the risk perception of a doctor performing acupuncture, the percentage of MD thinking that acupuncture has no risk or low risk increases, and the percentage of medium and high risk decreases.
Table 4 – The perception of risk of different therapies and of Acupuncture, according to the performer
Questions None Low Medium High Do not know 18. What do you think about...
18.1 Acupuncture Risk? 12.6% 52.9% 25.3% 3.4% 5.7% 18.2 Phytotherapy Risk? 3.4% 31.0% 28.7% 9.2% 27.6% 18.3 Homeopathy Risk? 10.3% 28.7% 34.5% 10.3% 16.1% 18.4 Tuina Risk? 6.9% 16.1% 5.7% 0.0% 71.3% 18.5 Qigong Risk? 8.0% 19.5% 4.6% 0.0% 67.8%
19. what do you think about the risks of application of acupuncture by:
19.1 Medical Doctor? 17.2% 66.7% 14.9% 1.1%
19.2 Nurse? 6.9% 51.7% 29.9% 11.5%
19.3 Physiotherapist? 4.6% 48.3% 33.3% 13.8% 19.4 Other health care professional? 3.4% 10.3% 32.2% 54.0% 19.5 TCM Technician without prior health education? 1.1% 14.9% 33.3% 50.6%
How Portuguese doctors perceive Traditional Chinese Medicine and its implementation in the National Health System: A pilot study 11
4. Discussion
This study has given access to preliminary data showing that Portuguese MD are open-minded towards TCM and that they generally perceive TCM positively. But this study also indicates that Portuguese MD do not know what TCM really is and, as expected, there is a misunderstanding between TCM and acupuncture. Even so, MD think that TCM therapies present low risks for patients, especially if treatments are applied by an MD, nurse or physiotherapist. In fact, most of the surveyed MD are open to recommending TCM to their patients. For most MD, TCM should be available on the NHS and TCM treatments should require a medical prescription.
This survey had a low response rate, as expected in this type of study [VanGeest et al., 2007]. The full extent of the phenomenon can be understood when analysing the specific audience of the survey: MD. It is known that questionnaires’ response rates are usually low, especially when involving MD, since they receive almost daily requests to participate in various types of surveys. Another aspect that may have affected the response rate was the fact that the questionnaire was sent during the month of August, a typical holiday month in Portugal. Although the questionnaire was available for a short time, one and a half months, this does not appear to have contributed to the low response rate, since the last response submitted was received on the 8th of September and the questionnaire was available until 14th of September. Bearing that in mind, it can be said that e-mailing the questionnaire to MD does not seem the best way to contact them. Possible solutions to overcome this situation could be to send a letter or even contact the MD in person, but any of these solutions will increase the cost of the study. Other possible approaches would require the active collaboration of the OM in this study. Finally, the study could be carried out during MD national conferences (bearing in mind this would not represent all MD).
The exact response rate cannot be truly calculated, because the actual number of MD who received the e-mail with the link to the questionnaire is unknown: the paid database may be out-of-date and just two of the thirty two contacted entities replied to the e-mail, one affirmatively and the other refusing to pass it on. Still, the response rate could have been increased with a second e-mail reinforcing the request for participation, but for that to be successful it would be necessary to have the MD’s direct e-mail address.
After analysing the received answers, some problems were found in the questionnaire, which will be explained next.
How Portuguese doctors perceive Traditional Chinese Medicine and its implementation in the National Health System: A pilot study 12 The checklist questions were not properly identified and so it could have been unclear to participants that they could select more than one answer, which could have an impact on the results. In the first questions, the age classes are unevenly distributed. They should have a 10-year range but one class covers 20 years.
The 10th question produced ambiguous results. This situation should be avoided and perhaps it would be more suitable to use a semantic differential scale. Another change needed in the 10th question would be elimination of the option “interesting”. It was concluded that this option was ambiguous and does not allow for a real perspective of MD opinion of TCM.
Question 16 should be eliminated, because contrary to what was expected, there were no significant differences between the answers to the 15th and the 16th questions. Therefore, it is more appropriate to keep just the 15th question.
The most important insight produced by this pilot study was through the 11th question: it showed that Portuguese MD do not know what TCM is, and that leads us to question the entire study. If MD do not know the meaning of TCM, all questions referring to such meaning/concept are worthless. For a future survey, presentation of a TCM definition and even a short definition of TCM techniques is suggested at the beginning of the questionnaire. This will at least ensure that the subsequent answers relate to the same definition of TCM.
The method chosen does not guarantee the representativeness of the sample. In this pilot study case, the sample is not representative of the MD population (at least concerning gender or medical speciality). It is suggested that in a future study a more specific population is chosen (e.g. one specific medical speciality, or MD from a given hospital) or opting for the Delphi research method, which uses an expert panel to formulate opinion of a determined subject in a given group [Comissão Europeia, 2008].
The designed questionnaire, in its current form, is not suitable, nor will it be able to produce valid output. To comply in terms of suitability and validity, before extending the initial survey to a field study, the questionnaire must be modified as suggested. Also, the method chosen should be reconsidered to guarantee both internal and external validities. If the survey method is kept, the distribution method and target population should be revised.
How Portuguese doctors perceive Traditional Chinese Medicine and its implementation in the National Health System: A pilot study 13
5. References
ALMEIDA, J. 2008. O debate político e o conflito inter-profissional em redor da regulamentação das medicinas alternativas e complementares em Portugal. VI Congresso Português de Sociologia. Universidade Nova de Lisboa.
COMISSÃO EUROPEIA 2008. Guia para a Avaliação do Desenvolvimento Socioeconómico - EVALSED. Manual Técnico II: Métodos e Técnicas de Avaliação.
COUNCIL OF EUROPE 1996. EUROPEAN SOCIAL CHARTER (REVISED). European Treaty Series.
FERREIRA, A. A. 2010. A Acupunctura na Madicina, Edições Lidel.
GRETEN, H. J. 2010. Understanding TCM: Scientific Chinese Medicine - the Heidelberg Model.
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How Portuguese doctors perceive Traditional Chinese Medicine and its implementation in the National Health System: A pilot study 15
Annex A: Critérios de Reconhecimento de Cursos de Pós
‐Graduação em
Acupunctura Médica e Obtenção da Competência em Acupunctura Médica
Disponível no sítio da internet da Sociedade Portuguesa Médica de Acupunctura, em
http://www.spma.pt/wp-content/uploads/2011/06/Crit%C3%A9rios-aprovados-pela-OM-em-Junho-2010.pdf, consultado em 12 de Agosto de 2012.
A Comissão de Competência em Acupunctura Médica pretende rever os critérios de reconhecimento dos Cursos de Pós‐Graduação em Acupunctura Médica realizados em Portugal, tendo como objectivo a uniformização da formação médica nesta área, promovendo a Acupunctura como técnica terapêutica válida e enquadrada na prática da Medicina, de acordo com os conhecimentos científicos actuais e na defesa da qualidade assistencial.
Os Cursos de Pós‐Graduação em Acupunctura Médica deverão cumprir o objectivo de formar médicos para a prática segura, eficaz e baseada em evidência científica e clínica, segundo a leges artes desta técnica terapêutica, assegurando que os formandos se encontram aptos para a prática da Acupunctura no final da realização dos mesmos.
1 – Critérios para reconhecimento dos Cursos de Pós‐Graduação em Acupunctura
Médica
Assim, a Comissão de Competência em Acupunctura Médica, considera que para terem o reconhecimento da Ordem dos Médicos, os Cursos de Pós‐Graduação em Acupunctura Médica a serem realizados em Portugal deverão cumprir os seguintes critérios:
a) Local de realização dos Cursos: os Cursos de Pós‐Graduação em Acupunctura Médica deverão realizar‐se em Universidades Públicas ou Privadas com idoneidade reconhecida legalmente, preferencialmente ligadas ao ensino das Ciências da Saúde,
b) Critérios de admissão aos Cursos: todos os alunos dos Cursos deverão ser médicos legalmente habilitados ao exercício da medicina.
c) Carga Horária: os Cursos de Pós‐Graduação deverão ter uma carga horária mínima de 300 horas de formação, das quais pelo menos 150 horas serão horas de contacto em presença física,
De forma a assegurar a qualidade do ensino desta técnica terapêutica, o programa de formação deverá contemplar um período mínimo de 40 horas em presença física dedicadas à prática de técnicas de punctura, sob supervisão dos docentes.
How Portuguese doctors perceive Traditional Chinese Medicine and its implementation in the National Health System: A pilot study 16 d) Conteúdos obrigatórios dos Cursos: o programa dos Cursos deve ter em atenção a evolução que a Acupunctura tem tido nas últimas décadas, quanto ao conhecimento dos seus mecanismos de acção, não esquecendo a história milenar e experiência desta técnica terapêutica. Assim todos os seguintes temas deverão estar obrigatoriamente incluídos no programa de formação dos Cursos:
- Bases neuro‐anatómicas e neuro‐fisiológicas da Acupunctura, - Investigação e Medicina Baseada na Evidência,
- Indicações, contra-indicações e efeitos adversos da Acupunctura, ‐ Bases teóricas da Medicina Tradicional Chinesa,
‐ Nomenclatura, topografia e anatomia dos meridianos e pontos,
e) Corpo docente: todo o corpo docente deve ser constituído exclusivamente por Médicos, privilegiando os que possuem Competência em Acupunctura no que respeita à formação específica nesta técnica terapêutica; poderão fazer parte do corpo docente médicos com formação específica em outras áreas do conhecimento médico, sempre que tal se justifique,
f) Metodologia de Avaliação: a aprendizagem de cada aluno deve ser avaliada através de exame teórico final ou exames realizados ao longo do Curso. Também será obrigatória a realização de um ou mais exames práticos, sendo este(s) exame(s) focado(s) na técnica de punctura, de forma a assegurar que no final do Curso todos os alunos se encontram aptos para a prática segura da Acupunctura. Os alunos deverão ter aprovação em cada uma destas formas de avaliação. Outras formas de avaliação serão opcionais.
2 - Reconhecimento dos Cursos pela Ordem
O reconhecimento dos Cursos pela Ordem dos Médicos deverá ser requerido ao Conselho Nacional Executivo, conforme o Regulamento da Avaliação da Formação do CNAF da Ordem dos Médicos.
3 - Entrada em vigor dos Critérios de Reconhecimento pela Ordem dos Médicos de Cursos de Formação Pós‐graduada em Acupunctura Médica
a) Os Critérios de reconhecimento pela Ordem dos Médicos dos Cursos de Formação Pós‐Graduada em Acupunctura Médica apresentados neste documento deverão ser aplicados a todos os Cursos de Formação Pós‐Graduada que se iniciem após 6 meses da sua aprovação pelo Conselho nacional Executivo da Ordem dos Médicos.
How Portuguese doctors perceive Traditional Chinese Medicine and its implementation in the National Health System: A pilot study 17
4 - Regime de transição
a) Até à entrada em vigor destes Critérios, médicos que se candidatem à Competência em Acupunctura Médica sem serem titulares de um Curso reconhecido pela Ordem dos Médicos devem submeter o seu currículo onde constem a estrutura curricular, corpo docente e metodologia de avaliação do Curso de que são titulares, bem como relatório da sua prática clínica de Acupunctura Médica. Após a avaliação do currículo do Curso, a Comissão da Competência decidirá:
i) se o currículo do Curso de que o candidato é titular corresponder aos critérios aprovados para a formação Pós‐Graduada em Acupunctura Médica, o candidato deverá cumprir o processo de formação continuada, da mesma forma que os médicos Ordem dos Médicos titulares de um dos Cursos de Formação Pós‐Graduada reconhecidos pela Ordem dos Médicos e submeter‐se no final desse período a avaliação curricular;
ii) se o currículo do Curso de que o candidato é titular for insuficiente para aprovação, a Comissão de Competência decidirá que valências o candidato deverá frequentar e obter aprovação antes de se candidatar para a atribuição da Competência em Acupunctura Médica. Após ter aprovação nestas valências, deverá cumprir o processo de formação continuada, da mesma forma que os médicos titulares de um dos Cursos de Formação Pós‐Graduada reconhecidos pela Ordem dos Médicos e submeter‐se no final desse período a avaliação curricular;
iii) se o currículo do Curso de que o candidato é titular for considerado inadequado para a atribuição da Competência em Acupunctura Médica, o candidato que queira obter essa Competência deverá frequentar um dos Cursos de Pós‐Graduação reconhecidos pela Ordem dos Médicos e realizar posteriormente o Programa de Formação Continuada com o período mínimo de 12 meses, após o que se submeterá a avaliação curricular.
5 - Acesso à Competência em Acupunctura Médica após entrada em vigor dos Critérios: a) Após a frequência com aproveitamento de um Curso de Formação Pós‐Graduada em Acupunctura Médica previamente reconhecido pela Ordem dos Médicos, todos os médicos que desejem ser‐lhes atribuída a Competência deverão obrigatoriamente cumprir os seguintes requisitos:
i) Período de formação continuada de pelo menos 12 meses, durante o qual todas as actividades listadas abaixo serão valorizadas na avaliação curricular:
How Portuguese doctors perceive Traditional Chinese Medicine and its implementation in the National Health System: A pilot study 18 ‐ publicação de artigos sobre Acupunctura Médica, em revistas médicas ou apresentações oral ou escrita em reuniões científicas Médicas,
‐ participação como formadores em Cursos de Formação Pós‐Graduada em Acupunctura Médica,
‐ frequência de acções de formação continuada,
‐ participação em outras acções relevantes para a prática e divulgação da Acupunctura Médica.
ii) Elaboração de um relatório com a descrição sumária do tratamento efectuado a 10 doentes (diagnóstico, esquema terapêutico detalhado, resultado do tratamento e follow‐ up),
iii) Durante o período de 12 meses até à realização da avaliação curricular, a prática poderá ser tutelada por médico com Competência Médica em Acupunctura. No final deste período de formação o tutor poderá redigir uma informação acerca do progresso do seu tutorando, que será incluída na avaliação curricular.
b) Terminado este período, deverão requerer a avaliação curricular, onde conste a sua formação e prática de Acupunctura Médica e o relatório referido no ponto 5, alínea a) ii).
6 ‐ Atribuição da Competência em Acupunctura Médica a Médicos que tenham realizado a formação Pós‐Graduada em Acupunctura fora de Portugal.
a) Médicos portugueses ou estrangeiros que tenham realizado formação com aproveitamento em outros países em que exista regulação da formação e prática da Acupunctura Médica, tendo‐lhes sido reconhecida a capacidade para a prática da Acupunctura Médica nesse país, e estando em condições legais para o exercício da Medicina em Portugal, poderão requerer à Ordem dos Médicos a atribuição da Competência em Acupunctura Médica, tendo para o efeito que submeter o seu Curriculum Vitae, onde deverão constar as informações referentes à estrutura curricular do Curso de Formação Pós‐Graduada de que são titulares, como definido em 1,
b) após avaliação do Currículo Vitae, a Comissão de Competência decidirá em que situação se encontra o candidato, tal como definido em 4 a),
d) caso seja considerado que a estrutura curricular do Curso de que é titular é adequada para a formação Pós‐Graduada em Acupunctura Médica, e tendo o candidato prática de
How Portuguese doctors perceive Traditional Chinese Medicine and its implementation in the National Health System: A pilot study 19 Acupunctura Médica, poderá a Comissão conceder a Competência Médica em Acupunctura, dispensando o período de formação continuada de 12 meses. [SPMA, 2010]
Coordenador: Dr. João Manuel Pires da Silva
How Portuguese doctors perceive Traditional Chinese Medicine and its implementation in the National Health System: A pilot study 20
Annex B: Questionnaire
Qual a percepção que os médicos Portugueses têm da MTC e da sua possível implementação no SNS. *Obrigatório 1. Idade * < de 30 anos 30 a 49 anos 50 a 59 anos 60 a 69 anos >70 anos 2. Género * Feminino Masculino 3. Nacionalidade * Portuguesa Outra: ____________
4. Onde tirou a sua Licenciatura em Medicina? * Portugal
Outra:_____________
5. Se na questão anterior assinalou "Portugal". Assinale em que Universidade se formou. Universidade do Minho
Faculdade de Medicina da Universidade do Porto Instituto de Ciências Biomédicas Abel Salazar, Porto Faculdade de Medicina da Universidade de Coimbra Universidade da Beira Interior
Universidade de Lisboa – Faculdade de Medicina
Faculdade de Ciências Médicas da Universidade Nova de Lisboa Universidade do Algarve
How Portuguese doctors perceive Traditional Chinese Medicine and its implementation in the National Health System: A pilot study 21
6. Especialidade Médica * Medicina Interna
Medicina geral e familiar Medicina física e reabilitação Ginecologia e Obstetrícia Urologia Cardiologia Oncologia Ortopedia Neurologia Psiquiatria Otorrinolaringologia Gastroenterologia Pneumologia Pediatria Dermatologia Cirurgia Outra:_____________________ 7. Local de Trabalho * Público Privado Ambos
8. Onde se encontra o seu local de trabalho? * Litoral Norte Litoral Centro Litoral Sul Interior Norte Interior Centro Interior Sul Madeira Açores
9. Tem alguma formação em Medicina Tradicional Chinesa? * Sim, fiz uma formação.
Não
How Portuguese doctors perceive Traditional Chinese Medicine and its implementation in the National Health System: A pilot study 22
9.1. Se anteriormente assinalou "sim", indique que tipo de formação realizou e a duração da mesma.
10. A Medicina Tradicional Chinesa é... * Eficaz Ineficaz Segura Insegura Placebo Interessante Sem valor
11. Fazem parte da Medicina Tradicional Chinesa... * Qigong Quiropraxia Dietética Fitoterapia Tuina Hipnoterapia Acupunctura Aromoterapia Shiatsu Reiki Hidroterapia
12. Já recorreu a tratamentos de Medicina Tradicional Chinesa
Sim Não
12.1. Se respondeu "sim" na questão anterior. Ficou satisfeito? Sim
How Portuguese doctors perceive Traditional Chinese Medicine and its implementation in the National Health System: A pilot study 23
13. Recomendaria tratamentos de MTC a um paciente seu? * Sim
Sim, já recomendei. Não
14. Acha que os tratamentos de MTC deveriam estar sujeitos a prescrição médica? * Sim
Não
15. Quem acha que deveria poder frequentar os cursos e aplicar a MTC? * Médicos Farmacêuticos Enfermeiros Psicólogos Fisioterapeutas Terapeutas ocupacionais Outros profissionais de saúde Profissionais das ciências da vida Qualquer pessoa
16. Quem acha que deveria poder frequentar os cursos e fazer investigação em MTC? * Médicos Farmacêuticos Enfermeiros Psicólogos Fisioterapeutas Terapeutas ocupacionais Outros profissionais de saúde Profissionais das ciências da vida Qualquer pessoa
17. No seu local de trabalho os pacientes têm acesso a algum tipo de Terapia Complementar?*
Sim Não
How Portuguese doctors perceive Traditional Chinese Medicine and its implementation in the National Health System: A pilot study 24 17.1. Se respondeu “sim” na questão anterior. A que tipo de Terapias Complementares têm os pacientes acessos?
Acupunctura Osteopatia Reiki
Outra:____________
18. O que pensa sobre o risco da utilização de:*
Nenhum Baixo Médio Elevado Não sei
Acupunctura Fitoterapia Homeopatia
Tuina Qigong
19. O que pensa sobre os riscos da aplicação de acupunctura por parte de:*
Nenhum Baixo Médio Elevado
Medico Enfermeiro Fisioterapeuta Outro profissional de saúde não médico Técnico de MTC sem formação prévia em saúde
20. Acha que a MTC deveria estar acessível no Sistema Nacional Saúde? * Sim
Não
How Portuguese doctors perceive Traditional Chinese Medicine and its implementation in the National Health System: A pilot study 25
